• Podcast
  • Oct 26 2018

'Behind the Blue': Sharon Walsh Discusses Kentucky's Opioid Epidemic

Drug addiction is rampant in the nation, with estimates of more than 70,000 people dying from drug overdoses in 2017, much of that fueled by opioid abuse.

To put it in relatable numbers, the United States suffered more deaths to drug abuse last year than the total number of U.S. soldiers killed in the Vietnam War. Or, put another way, at roughly 200 deaths per day, it’s the equivalent of a jumbo jet going down every 24 hours.

The problem has reached epidemic levels in Kentucky, with heroin and fentanyl abuse ravaging communities. On this week’s episode of "Behind the Blue," Sharon Walsh, director of the University of Kentucky’s Center on Drug and Alcohol Research (CDAR) and a distinguished professor in the UK College of Medicine, discusses the challenge Kentucky faces in battling the opioid epidemic.

That question – what do we do? – was the basis of a daylong meeting Walsh had with the UK Board of Trustees. As part of its annual retreat this year, UK President Eli Capilouto and Walsh framed an entire day of discussion and presentations around the opioid epidemic in the country and its specific impact on Kentucky.

As importantly, the discussion centered on how UK – along with partners at the state and federal levels – is positioning itself to stem the tide of drug addiction and abuse in the state and beyond those borders.

[intro music]

From the campus of the University of Kentucky, you're listening to Behind the Blue!

Kody Kiser: Drug addition is rampant in the nation, with estimates of more than 70,000 people dying from drug overdoses in 2017. Much of that fueled by opioid abuse. To put it in relatable numbers, the United States suffered more deaths to drug abuse last year than the total number of US soldiers killed in the Vietnam War. Or, put another way, at roughly 200 deaths per day, it's the equivalent of a jumbo jet going down every 24 hours. I'm Kody Kiser with UK PR and marketing. And I'm joined this week by my colleagues Olivia Ramirez and UK PR Director Jay Blanton. 

The problem has reached epidemic levels in Kentucky, with Heroin and Fentanyl abuse ravaging communities. On this week's episode of Behind the Blue, Dr. Sharon Walsh, Director of the University of Kentucky's Center on Drug and Alcohol Research, or CDAR, and a distinguished professor in the UK College of Medicine, discusses the challenge Kentucky faces in battling the opioid epidemic. That question, what do we do, is the basis of a day long meeting with the UK Board of Trustees. As part of their annual retreat this year, UK President Eli Capilouto and Dr. Walsh have framed an entire day of discussion and presentations around the opioid epidemic in the country, and its specific impact on Kentucky. As importantly, the discussion was centered on how UK, along with partners at the state and federal levels, is positioning itself to stem the tide of drug addiction and abuse in the state and beyond those boarders. 


Kiser: We are joined this week on the podcast by Dr. Sharon Walsh, who is the director for the Center on Drug and Alcohol Research. Also, a professor of behavioral science, psychiatry, pharmacology, and pharmaceutical sciences. Did- That's a lot. Did I get all of those? 

Dr. Walsh: You did. 

Kiser: I did? 

Dr. Walsh: Yes. 

Kiser: Okay. Is there anything I missed? 

Dr. Walsh: No. I don't think so. 

Kiser: Anything extra that we don't know about that is part of your - your - the titles that you may hold?

Dr. Walsh: No. Not really. I do a lot of external work as well, and so, for example, Service Adviser to the Food and Drug Administration. But we don't need to list those other activities. 

Kiser: Okay. Okay. First of all, the first thing we always ask anybody who comes in to join us, is tell us about your journey. How you ended up here at the University of Kentucky. And how long have you been here? 

Dr. Walsh: I have been at the University of Kentucky since 2005, so 13 years. And before that, I was at Johns Hopkins University in their school of medicine for about 15 years in Baltimore. And I trained at Rutgers University in Behavioral Neuroscience. I went on to do a fellowship at Johns Hopkins to learn how to conduct Human studies in clinical pharmacology. And that was when I first became interested in substance abuse. And I was fortunate to stay on there and go through the ranks until I was a professor. And then the University of Kentucky lured me away from Baltimore, and we've been here ever since, and it's been a really terrific opportunity. 

Kiser: Now, are you from the East Coast originally? 

Dr. Walsh: I am from the East Coast. I'm from Philadelphia. That's where I grew up, and I spent really all my life on the East Coast in Pennsylvania, Northern New Jersey, and Baltimore before coming to Kentucky. 

Kiser: Pennsylvania doesn't seem like too much of a culture shock or difference from Kentucky in some ways. I mean, there's some similarities I would suppose? 

Dr. Walsh: There are a lot of similarities, I would say, between Central Pennsylvania and Central Kentucky. But, being from the Eastern part in Philadelphia, which is, you know, obviously a really large city. There's a lot of differences. Because I had been raised and worked for so many years on the East Coast, when I came to Kentucky, a lot of my colleagues were surprised that I made the decision. And several of them said to me "Well, it must be quite a culture shock." And I think they meant it in a derogatory way. Because, people have some, you know, ideas about Kentucky that aren't true. And I always responded, "Only in the best possible way." It's a culture shock only in the best possible way, because it's such a great place to live. And it's so beautiful here, and people are so kind. And there's a great sense of community. 

Kiser: So, one of the things we wanted to talk about is the upcoming annual Board Retreat. And one of the things, specifically with that, is that Dr. Capilouto has - had a large amount of concern about the opioid epidemic here in the state and has asked you to basically provide information and walk them through kind of an understanding of what the situation is, and how serious it is, and what we can do to move forward with it. Elaborate a little bit on that and explain exactly what's going to happen with that. 

Dr. Walsh: The opioid crisis is really probably the biggest public health crisis that we've faced in this country in a long time. And, despite a lot of efforts that are underway right now to change the course of things, with each successive year, we've had a greater number of overdose deaths. And the deaths are the thing that are getting the attention of the media, but there's just a tremendous amount of fallout aside from the overdose deaths. Including transmission of infectious diseases, loss of parents, loss of the structure in the family, high rates of incarceration for minor drug charges. And so, this crisis is really tearing apart the fabric of our society and, I think, that it's going to be felt for generations to come. So, we have a lot of scientific evidence around what can work to change the course of the current crisis, but we haven't historically had very organized structure around treatment for substance abuse disorders in the United States. And part of that is just that it has historically been separated from mainstream medicine. And what's really needed is for it to be integrated into general medical care, because the problem has become so pervasive. 

President Capilouto has been very interested in this issue, because it has such a great impact on the Commonwealth. And he comes from a public health background himself. And, he has spent a lot of time reading and educating himself about the crisis, and he and I have worked together on a number of things over the last couple of years with the aim of really trying to make a difference in the community. At the University of Kentucky, we have a tremendous number of faculty who are very skilled and very dedicated, and are recognized as national experts in their fields, doing work on different aspects of the crisis. And so, we really have a large group of talented and concerned faculty that are focused on this, and I think it positions the University of Kentucky to really make a difference. And I think that President Capilouto recognized that when he had the opportunity to see some of my colleagues present at a meeting that we had, where we invited the director of the National Institute on Drug Abuse, Dr. Nora Volkow, to come from Washington and hear about all the good things that were happening here. 

Dr. Walsh: And since then, we've just had a lot of momentum. President Capilouto then had the idea of focusing the Board of Trustees' Meeting on this crisis. Because he saw it as an opportunity to have the Trustees learn more about the origins of the crisis, and the current public health impact that it's having. And of course, our Trustees are all very influential people that have roles around the state. And, to make a difference in the community, and to try and stop this devastating crisis, having more people understand the dimensions of it, understand the evidence around interventions that work - both in the business community and in the political arena - for people who have influence over making policy decision that actually impact our ability to deliver care - that's the next step in this. As scientists, we know what works, but having that science implemented in community settings is the next step. And that's one of the things we're working on now. So, the more we talk about, and the more we educate people, we think the more traction we'll get with changing the course of things. 

Kiser: Give us a sense - do you want to give us the sense of the day and what all's going to take place, but for a little context, can you give us a little more sense of the scope of the problem? Nationally and locally, when you talk about it tearing up the fabric of communities and the different things like incarceration and disintegration of families. Can you give us a little more sense of the scope of what you mean there? 

Dr. Walsh: With respect to fatal overdose deaths? It's estimated that for this past year, 2017, that more than 72,000 people will die from a drug overdose, with a large majority of that being directly attributed to opioid drugs. That is likely a significant underestimation, because in this country, we don't really have a central system for coroners and medical examiners. We don't have consistency for testing. And also, there's a lot of stigma around an overdose death that's related to drugs, so often times, families don't want that on the death certificate, because they're embarrassed. So, we know that the numbers are even greater. 

But, even with that number, that's more people than the total number of people who died in the Vietnam War. So, we're loosing about 200 people a day. Which would be the equivalent of a, you know, jumbo jet going down every single day in this country. And, if that were to happen, you can imagine that there would be a great public outcry and all the jets would be grounded until we figured out what was wrong. And that's not exactly what's happening in this situation. In addition, of course, if people progress their drug use to injection drug use, then they're at risk for transmission of HIV and Hepatitis C. The data that we have in our cohorts of individuals that we follow, suggest that approximately somewhere between 60 to 75 percent of the people who are injecting drugs are currently infected with Hepatitis C. And treatment for Hepatitis C is quite expensive. It's not widely available for everyone, and the risk for Hepatitis C is that ultimately, people will develop Liver Cancer and die from that. That will be a consequence that we'll see much later. 

Dr. Walsh: In Eastern Kentucky, there is one school where less than 50 percent of the children actually have a parent living in the home. Because either their parents have died from a drug overdose, or the parents are currently locked up in jail or in prison for a drug related charge. So those children are living with grandparents or other family members. We're seeing inter-generational affects now, where parents are using and then that's what the children are seeing, and so then the next generation is getting involved in opioid use as well. 

It's really just a terrible thing. And one of the things that we have learned, in the course of this epidemic, is that it doesn't discriminate. So, it is affecting people of all classes, all races, all socioeconomic status, all levels of education. And it's a very, very unforgiving disorder. And when you think about the people that are actually dying of overdose, they're relatively young. So, we're really loosing a lot of lives before people have had the chance to have their impact. 

Kiser: I just - that's stunning when you frame it in the context of a jumbo jet crashing per day. And the stark contrast of our reaction to what that would be like versus what this situation brings. Why is that? What are the factors there, socioeconomically or culturally that people just don't have that type of reaction to this? 

Dr. Walsh: There has always been a lot of stigma associated with drug abuse. Historically because our country has treated it as a crime, and as a moral failing, rather than potentially as a medical disorder. The response in this country has gone along with that position. So, you know, if it's a moral failing, then you're a bad person, and you aren't deserving of good care. And if it's a crime, then we'll just lock you up, and that'll stop it. We're not winning the war on drugs. We've been fighting this war on drugs through interdiction and punishment. And it obviously isn't have that great of an impact, because we're in the throes of one of the worst epidemics that the country has ever experienced. And we're not seeing signs of it diminishing at this point. 

So, when people get caught up in drug abuse, there's a lot of shame that's attached to it. Families are ashamed, families are scared. They don't know what to do. It's hard to find good help sometimes. Part of it is because of that splintering of the treatment framework in this country. But, also, it's because people feel isolated, and they don't really know where to go to. You know, if you had a loved one who was diagnosed with a particular type of cancer, you could easily get online to the National Cancer Institute website and find out the exact perfect place where you might take your loved one to get the exact care that they need. We don't have that in substance abuse. 

Dr. Walsh: And, we're working on trying to improve that. The state of Kentucky worked really hard over the last year and a half to develop a live website that is called FindHelpNow. So, that a family can go in and look if they're trying to get a loved one into treatment, and see what programs actually have openings. But, we have very limited access and it's estimated in this country, that only about 1 in 10 people who need help for opioid addiction are actually able to access it. And some of that has to do with stigma, fear, cost, lack of insurance, and, you know, just an inability to navigate the system. 

Olivia Ramirez: So you said at the Board of Trustees Meeting, you're going to give an overarching view of all the different aspects of the opioid crisis, from, I'm assuming, prevention, treatment, harm reduction. Can you talk about some of the topics that are going to be covered, and some of the people maybe that are going to be speaking? 

Dr. Walsh: Sure. So we have a really full day planned. And I'm very excited about it. I think that it'll be a great learning opportunity for everybody who participates. We'll start off with just an overview and background on how the crisis got started, the role of the pharmaceutical companies, and then, what followed from there was an infiltration of illegal drug dealing that brought heroin and other illicit opioids into communities that had historically never seen them before. In the overview, we'll also talk about the best approaches to dealing with it. And those would include prevention, harm reduction, and treatment approaches. 

We will have a panel in the morning that will talk about treatment in different settings. And I think that this is going to be really interesting, and, I hope, a lively discussion. So we'll have two people from the state; one who is- oversees the justice system. That's Secretary John Tilley. And they're doing a lot of innovative things now around treatment in the jails and prisons, which is an area, of course, that has a lot of people who are impacted by substance use disorders. But historically, has not provided much in the way of evidence based treatment. We'll have Dr. Allen Brenzel, who is the medical director and is overseeing a lot of the new initiatives that the state is doing through the CURES funding from the federal government. And from the newest state opioid response money that's coming to Kentucky. 

Dr. Walsh: And then we'll have two faculty members who are both physicians at the University of Kentucky. One who is providing care in both inpatient and outpatient settings. And then - that's Dr. Laura Fanucchi. And she also provides care to people who have opioid use disorder and have HIV infection. And we will have Dr. Roger Humphries, who is our chair of the Emergency Department. And of course, the emergency department is a place where we see a lot of people coming in from the community, either because they've overdosed or because they have some other health consequence from injecting drug use.

So, for that panel, we'll have a lot discussion around how to introduce treatment, how to screen people, how to get people tied into treatment. And one of the things we'll be talking about is a new initiative that the University of Kentucky has launched in partnership with the state, and that is the development of what's called the First Bridge Clinic. And the First Bridge Clinic is tied directly to the Emergency Department, so that if someone comes in and overdoses, that they can be brought directly to the First Bridge Clinic and begin getting evidence based care from one of our physician providers. 

We will have a round robin rapid research presentation to talk about a couple of really big projects that are new to the University of Kentucky that are being funded by the federal government through the National Institutes of Health. National Cancer Institute and the National Institute on Drug Abuse. And that will be really instructive, and I think people will be excited to hear about those projects, because they're really making an impact in the community. And we will also have some community members who have been affected by opioid use disorder, and they're going talk about their experiences. 

Dr. Walsh: In the afternoon, we will have another panel, and that will focus on mothers and children who are impacted by opioid use disorder. We're going to have Natalie Kelly from the state foster care system. And she'll be able to talk about how the state is trying to manage foster care placements related to children who have either drug using parents in the home, or their parents are gone. And we'll have Dr. Agatha Critchfield, who is an OB/GYN who started the PATHways program - with other colleagues. She'll talk about that. And Kristen Ashford will talk about the Beyond Birth program - Beyond Birth program that supports mothers after they've delivered their children. 

Olivia Ramirez: Several times during you're overview, you said "evidence-based treatment". Can you talk a little bit more about what that is and how that compares to the type of treatment that people typically get in the United States? 

Dr. Walsh: That's a really great question. And I'm happy to talk about it. In the United States, the most common approach to treatment is probably detoxification. And detoxification simply means the process of getting someone through the initial, painful withdraw symptoms that occurs when they stop using opioids. But it doesn't actually do anything to treat the underlying disorder. Because, by the time that someone develops an opioid addiction, the problem is not just pharmacological. Typically, by the time that someone comes into treatment, they have suffered a lot of other losses. And they may have no employment, or low employment. They may have ruined their personal relationships with their loved ones; their parents, their spouse. They may have unstable housing. And, in some cases that can be a consequence of their drug use. But in many cases, what we know, is that there are antecedents or predictors of things that will lead someone down the path of becoming opioid addicted.  

And so, for example, we know that a lot of people that are diagnosed with opioid use disorder will have a history of childhood trauma, or sexual abuse, particularly for women. They'll have anxiety disorders or other problems that have gone diagnosed and so, if you simply remove the drug from the equation, that does not make the person whole. It doesn't change the things that preceded the drug use that may be problematic. And it doesn't change the psycho-social factors now that they have to deal with as a consequence of their drug use. And so, we think of opioid use disorder as a chronic, relapsing brain disorder. And what that means is that it's chronic, so that once someone has developed an opioid use disorder, they're at risk for the remainder of their life. They need to stay, you know, working on their recovery. 

Dr. Walsh: Many of the treatment programs that can be found in the community are not evidence-based in that they are relying on, perhaps, the 12 step philosophy that emerged in this country decades ago around alcohol use. We know that alcohol abuse is not the same as opioid abuse. We shouldn't make the leap to assume that things that may work for some people who have an alcohol problem should work for all people who have an opioid use disorder. And, unfortunately, that is the case in many treatment settings. And, most unfortunately, that can be fatal. 

So, what we know about detoxification is that, that actually increases the risk of somebody dying of a subsequent overdose. If you look at the rate of overdoses that occur, for example, right after someone leaves detoxification or leaves jail, where they have been forcefully detoxified, the risk of overdose is substantially higher in the first few weeks after they have completed that detoxification. And part of that is because their pharmacological thermometer has kind of been reset. And so now, they're not tolerant to the same dose they could have taken before. Now that same dose will actually kill them. And, when we look at studies that have evaluated detoxification, what we know, is actually that it increases the risk for death and that it does not promote retention in treatment. And because we think that treatment needs to be somewhat long-term, that people need to work on those other psycho-social issues once we get the pharmacology part of it under control, the idea that you could do a five day detox and suddenly everything is going to be fine, is very naive. 

Dr. Walsh: When we talk about evidence-based treatment, in the case of opioid use disorder, we really understand a lot about the neuropharmacology related to the disorder. And we have three medications that are approved by the Food and Drug Administration for the treatment of opioid use disorder, and these are Methadone, Naltrexone, and Buprenorphine. And each of those medications, when used properly, will reduce illicit opioid abuse. It will reduce the transmission of disease. They'll block the affects, if somebody had relapsed, say, and they have a slip and they try heroin for example. Each of those medications will actually block the effect of Heroin. So that they don't really get any reinforcement for using it. And that's another way that these medications work, is they kind of extinguish that behavior. They prevent overdose because they block the respiratory depressant affects of an illicit opioid. And, in general, in studies of long term treatment with medications, we find that they promote reintegration into society. They promote employment. They promote restoration of family structure. 

Kiser: You think we're getting more acceptance of this sort of medical-assisted approach? Because there's a stigma associated with that as well, right? I mean...

Dr. Walsh: Right. I mean this is the - Yeah. I think this is the only disorder- medical disorder - that I can think of in the country where someone would purposefully withhold a treatment that we know works. And part of that is the stigma that is associated with using medications. And, a lot of that really stems from this older tradition of thinking about what abstinence means. So, in the 12 step community, historically, abstinence meant abstinence from everything. So, if you had a problem from alcohol, not only weren't you supposed to not use alcohol, you also, if you had depression, you shouldn't use anti-depressants either. So there was this kind of very strident belief system that you should be able to pull yourself up by your bootstraps, and just be, you know - not depend on any kind of medication at all. And that's obviously not a very healthy approach to the problem, because we know that people suffer from depression, for example, and if they didn't have a substance use disorder, we wouldn't have any problem with them taking a psychiatric medication that would help them with their mood disorder. 

We would never tell somebody that we're going to withhold their insulin who's diabetic, because they had a donut, you know. That's exactly what happens in this scenario. Where somebody can come into treatment, they can be doing well, and they may test positive for marijuana, and then they get kicked out of treatment. Well, this medication's not meant to treat marijuana. It's meant to treat the opioid problem. And so, if someone is in treatment and they're using, or they're having slip ups, that, to a good clinician, should be an indicator that that person needs more treatment, and not less treatment. 

Dr. Walsh: And so, in a good structured program, what you would do is you would escalate the requirements for that patient. Maybe they would need to come in more frequently, or if you had concerns that they weren't using their medication properly, maybe they would need to come in and have it supervised by someone. We do that at our clinic. And, you know, we have patients that are doing really well and have been in care for a couple of years, and may have abstained from everything for a really long duration, and then something happens in their life that just derails them momentarily, and they may go back to that crutch. And at that point in time, that's not a time to remove them from treatment. That's the point where we really need to wrap everything around them to get them back to where they need to be. 

Kiser: You mentioned something earlier about the lack of, in some of these treatment programs, the lack of, you know, licensed professionals that work in some of these places. Why is there this scenario? What is the- Where's the oversight in this? And does that come from this kind of breakdown of we don't treat this like we treat other- other things? We don't treat these people like we would treat diabetics, for example. So, why are these particular things allowed to kind of operate in this area, this grey area, where there's no real clinical oversight in some cases? 

Dr. Walsh: It's really alarming actually, to think that that's what's happening, right? I - And it shouldn't be happening. I think it is the result of the historical context of things. And so, some of the programs don't receive federal money from an agency that knows about treatment, for example. Some agency- some treatment programs get money from SAMHSA and SAMHSA sets the standards for what good care is. So, for those programs, they will be held accountable. But there are other programs that get their support from the Criminal Justice System, as a place to transfer people from prison, or offload people - put them into long-term care as an alternative to being incarcerated. There are places that get money through Housing instead of treatment, and it's meant to help people that have unstable housing, and of course, a lot of those people may have substance abuse issues. And, so, they're really dressed up as treatment programs, except that what they're doing is not really delivering any evidence-based care. 

And, and that's not to say that those approaches may not work for some people. I think that everybody is different and certainly some people do well and succeed. But I think the thing I have more of a problem with is that any organization who purports to be providing treatment is able to receive any federal funding if they are actually withholding evidence-based care. In my - From my perspective, that's discrimination. And it's a discrimination that we would not tolerate for any other group of citizens in this country. 

Kiser: It's good to see a research institution like UK, that is located in geography where the problem is so pronounced. What do you see as the - it looks like the day you put together for the Board is sort of the holistic look at this problem, and how this institution can approach it. Is that part of what you think can communicate to the board is how we're positioning - how you and others are positioning the university to address this in a holistic fashion? Or what do you see coming out of this? And what is it we bring to the table, you think?

Dr. Walsh: The opioid crisis that we're facing is a lifespan crisis. This is a crisis that's actually affecting babies before they're born. And seniors. You know, throughout the whole lifespan. So, we really need to take a very holistic approach to dealing with this. And we need to be looking at new treatments that may be more effective. We need to be looking at novel models for treatment delivery. One of the things that we are spending time on is trying to figure out how to enhance treatment access in rural communities. Kentucky is a very rural state. And there are lots of regions in Kentucky where they have very little specialty medical care around most issues. You know, a lot of people have to travel some distance to get their medical care. And that's certainly the case for people with opioid use disorder. 

So, what we'd like to do is be able to demonstrate the effectiveness of new models of car. Ways to expand medication delivery to people that need it, so that we can have better coverage for people within the Commonwealth. We - While we do have a lot of community research underway, where we actually are in the communities working with people, trying to make a difference, trying to treat Hepatitis C, trying to expand access to medications, the work that we do here at the University of Kentucky is really very cutting edge. So, we're not just trying to set the standard for what we're going to do here in this state, we're actually trying to set the standards for what we should be doing in this country. 

Dr. Walsh: And so, as an example, over the last two years, we've been involved in the development of some new medicates that - one has been approved by the FDA, the other one we hope will be approved by the FDA later this year. And these are sustained release formulations that can be giving to someone once a month, and then, we don't have to worry about whether they're adherent to their medications. We don't have to worry about the medications going into somebody else's hands that they're not intended for. This can reduce the workload for physician offices as well, because you need, you know, perhaps fewer visits. They may lend themselves to doing telehealth models to reach the more remote areas that don't have good medical coverage. 

One of the projects that we are about to get underway is the only one of its kind that's happening in the country. We're going to go into Perry County and we are going to treat every single person who has Hepatitis C, and cure them. And we're going to use this as a model approach as treatment as prevention. So when you treat the people who are infected, then you're at a much lower risk for transmission to other people. And so, we're going to do this, and we're going to compare it to a control county that doesn't have access to all the medications. And if we get the expected findings, then we think that this may actually change the course of how Hepatitis C is addressed nationally. 

Kiser: So, it's almost like - something like that might be done in a lab, where you look at a treatment - or a clinical setting - look at a treatment and then have a controlled kind of setting. But here, you're actually going to go - I mean, this really is a community-based approach to a problem like this. Right? You're here, you're actually going to go into a county - look at it opposed to what's happening in another county, and make - And no - You had mentioned, no one in the country is doing anything like that? 

Dr. Walsh: No. No, and so this is a really big investment by the National Institute on Drug Abuse and the National Cancer Institute. And - so we feel very fortunate that they are supportive of this project. The project actually came about because both the director of NIDA and the director of NCI were invited to come to campus so that we could show off all the good work that we're doing here. And the two of them talked about this idea and thought that it would be a really important demonstration if they could find the money for it. And since more recently a lot of federal dollars have increased to address some of these, they were able to put this together. In addition, in a situation like that, in order to prevent infection or re-infection, you really want to be able to have a syringe services program. So that people can have access to clean syringes. They're not put in a position where they need to share needles. 

We know that syringe services programs are really excellent at reducing transmission of disease, and they're also a great way to identify people who have a problem and are not yet in treatment and link them to treatment. Previous studies have been published that have shown that syringe exchange services programs can actually increase the number of people referred and brought into treatment by 80 percent. So, we see those as a gateway - not just as a place for people to exchange needles. 

Dr. Walsh: But in order to conduct this study in Perry County, there was no syringe exchange program. So it would have been a bad idea to choose a place where people didn't have access to clean needles. And so the CDC and NIDA offered to pay for a syringe exchange program to open in Hazard, Kentucky. And Jennifer Havens is the principle investigator of this project. And so one of her first jobs was to try to persuade the people of Hazard, Kentucky that they needed a syringe exchange program. And that program was opened several months ago in anticipation of this project starting. 

Kiser: How do you go about changing attitudes within communities? And really making people - getting people to a place where they can see that it doesn't matter how removed you try to make yourself from this, you're being affected by this epidemic in ways that you can't even - you know, it's not just - You can't just look at it and say, well everybody in my family - You know - I don't have any people in my family that are affected by this. It's just - it's external. But that's not true. I mean, there's so much that people don't even see. It's not an increase in criminality, or you know, like people breaking into homes or things like that. But there are other things economically that you're being affected by that you probably don't even realize. 

Dr. Walsh: So, that's a complex question, because there are two parts to that. The first question you asked is how do you get people to change their minds. And that's really a challenge. I have been saying for the last year that my job description has changed. I've, historically, thought about myself as a scientist, and that my job was to do good science and to covey that to the public. And now I feel like a large part of my job is trying to change hearts and minds, and trying to teach people about evidence-based care. To help people recognize that this crisis is not discriminating. That everyone is being impacted. If you go into the communities that are really highly effected, you would be hard pressed to find someone who doesn't know someone who overdosed. If you talk to someone who is in the active stages of addiction, and you ask them if they know anyone who has died, they'll be able to, sadly, rattle off a long list of names. 

But there are a lot of other consequences. Some of which we've already talked about. But certainly, you know, there are - there's a lot of property crime that goes on to get money to have people support their habits. There's, you know, neglect of children, neglect of duties. It's- We have a very hard time hiring people in this state for jobs because people can't pass a drug test. But, you know, most employers aren't in a position to actually offer treatment. Although there are some innovative programs going on around the state now, focusing on that. 

Dr. Walsh: The problem with addiction is that everybody thinks they know what it is. Even if they haven't been impacted by it. So, if I were a neurosurgeon, and I went to a barbecue, no one would tell me how to do neurosurgery. They wouldn't assume that they knew that. That's not the case with drug addiction. Everybody has an opinion, everybody thinks that they know something about it. So, trying to get people to change their framework from think that this is purely a moral failing, to recognizing that there's a biological basis for it. That there are genetic vulnerabilities that predispose people to developing substance use disorders. That once somebody becomes opioid exposed and their use has escalated, that their brain has changed forever, and that that needs to be addressed in order to get them back to some set point where they can do well without illicit drug use. But we have a lot of work to do. 

I have to say that I've been doing research in this area for 25 years, and I would have never dreamt that I would be hearing senators, the president, police departments, jailers all talking about the importance of medication for opioid use disorder. But we are at a tipping point right now, where a lot of places are doing some more progressive things. They recognize that they are not going to arrest their way out of this crisis. We've been in the throes of this crisis for over a decade, easily. And our deaths were higher this year than any preceding year. So, we really need to change the framework and embrace the things that we know work, and try to get them delivered as easily and with a few barriers as we possibly can. 

Joy Blanton: Do you have some- I mean you said tipping point. Do you have some optimism that the attention of federal officials and other folks pointed in the right direction, that you can actually turn this around? 

Dr. Walsh: I do. I do. I - I think I'm eternally optimistic actually in general. But I am very optimistic, because we are regularly seeing evidence and seeing it in the lay press. So, for example, the New York Times has done a great job of running articles, at least once a week, about things that are working across the United States. One of the recent programs, for example, was the Rhode Island incarceration system, where they decided to provide treatment to everyone who needed it, while they're in job, and then upon discharge. And, of course, Rhode Island is a lot smaller than an other state. They have a centralized incarceration system, so it is a little easier to work in than states that are a little bit more complicated than ours. But they significantly reduced the death overdose rate of people who were discharging from jail in a very short period of time by just doing that intervention. 

I was in Vermont last week, at a meeting on this crisis, and Vermont has been very progressive in trying to have access to care for everybody who needs it. And they've developed this hub and spoke model where there's kind of an expert center in the hub, and then the spokes are the community centers that are, not necessarily drug treatment programs. They may be primary care doctors, family doctors, who will take care of patients in their own community that have opioid use disorder. And, in a relatively short period of time, Vermont has been able to move from very limited access to almost 100 percent coverage. And with that, they estimate that probably about 2 percent of their total state population actually requires care for opioid use disorder. So you could do those numbers for Kentucky, and you could see the number would be fairly substantial. But, these types of innovative programs that are largely being supported by state and federal funds, are demonstrating to the rest of the country what a difference you can make by putting the care in the right place. Meeting the patients where they are. And so, I think that, when there's such strong, robust evidence like that, it becomes harder to deny that those are things that are effective. And easier for people to buy into it. 

Blanton: Is there anything you think about the Board meeting or the focus of your work now that we're missing that you'd want to add, or you think we ought to include in this part of this conversation as part of what we're doing?

Kiser: In addition to that, where do you see your work, or this work, going 6 months, 12 months, 2 years down the road? Kind of a broad overview of where you see things heading with this. 

Dr. Walsh: There are a lot of new research initiatives that are funneling down from the NIH institutes. And we also have been fortunate recently, to receive a number of new grants that we're just getting underway. And they really cover a breadth of topics around this complex crisis. One project that we'll be starting will be to deliver medications in parole and probation offices. We know when people come out of jail that, if they're on parole or probation, that that's one place where they will need to come back to. And so we think that might be an interesting novel model of care. We would help staff those with a healthcare provider as well, so it wouldn't be a burden on that - on the parole or probation officer. It's really just a location where we know we would be interfacing with that patient. So that's one new project that we'll get underway. And we're excited about that. 

We continue to work on the development of new medications. So, for example, we have one project where we're looking at a novel receptor in the brain as a potential target for treating opioid use disorder. And we also recently obtained a grant in collaboration with our colleagues from Columbia University to look at a novel vaccine that would prevent opioid from actually entering into the brain in someone who was vaccinated. So that's a totally different approach from a biological perspective than the treatments that are currently available. 

Dr. Walsh: We know that when people die from an opioid overdose, it is common for there to be some specific other drug classes present. And we know that those seem to represent an additional or synergistic risk for overdose. But we don't really know the mechanisms behind that, so we have some really solid clinical-pharmacology studies planned where we'll be carefully evaluating the risk of overdose and respiratory depression of these drug combinations in our hospital setting where it's very controlled and people can be monitored really safely. 

Kiser: Is there anything that we didn't ask you about, or anything that you feel is important to point out or restate? Anything we didn't bring up that you think you'd like to mention? 

Dr. Walsh: One thing that we didn't really discuss is how we can go about increasing access to evidence-based care. And, while treatment for substance abuse disorders has historically been siloed outside of the medical system, I think that our best hope is to actually integrate it across medicine. And, sometimes, when I talk with physicians who may be in a position of providing care for patients, they'll say, well I don't actually have any of those patients in my practice. And my response to that usually is, "You definitely do, you just don't know it or you're not asking the right questions." And so, I think we need to do a much better job of training the health professionals around issues related to addiction, and encourage them to embrace providing care in the regular practice. Because, certainly people who are in primary care, family medicine, OB/GYN, all those people are seeing people who are affected that could benefit from good treatment. 

And, I think that we need to do a better job of integrating this type of curriculum into training for health professionals. We don't do a very good job with medical students or nursing students on the topics of addiction. We also don't do a very good job of teaching them about the harms of opioid prescribing. Part of the way that - the primary path that went down to find ourselves in this situation, or the initial precipitating effects that led to this crisis were the wild expansion of opioid prescribing by physicians. And, unfortunately, that's what they were being recommended to do. They thought they were being - those recommendations were coming from professional societies. But those professional societies were actually being pay-rolled by the pharmaceutical industry. And so, I think that the idea that for a physician to actually be able to prescribe, for example, Buprenorphine, which is one of the most effective treatments that we have, they have to get a special license to do that. But no one needs a special license to prescribe Oxycodone. So, every doctor can do that, but not every doctor can treat the problem that they actually may be causing. And that's really backwards, and we need to change that paradigm. 

Kiser: Dr. Sharon Walsh. We greatly appreciate the time. It is a very complex and layered issue that we've been discussing. I know that in this short amount of time, even, we have really only scratched the surface with it. And the complexity of it and how you approach it, how you treat it, and how different it is from patient to patient. So, thank you for your time. And as far as the Board Retreat and that presentation and all of your future work, we wish you the best of luck and best of progress. 

Dr. Walsh: Thank you very much. I really appreciate that. 


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